Can You “Scrape” Your Way Out Of Tennis Or Golfer’s Elbow Pain?
Instrument Assisted Soft Tissue Mobilization – or IASTM for short, is the general term for a group of techniques and the various tools used to apply them, the Graston Technique being the foremost.
There’s also Astym (Augmented Soft Tissue Mobilization) SMART Tools, HawkGrips, Functional and Kinetic Treatment and Rehab (FAKTR) and a similar ancient Chinese technique called Gua Sha.
With the exception of the bamboo Chinese tools used with Gua Sha, the modern variants use rather medieval-looking metal or ceramic instruments to apply a form of “scraping” pressure.
Chiropractors, Physical Therapists, Massage Therapists and other practitioners often use these tools and techniques to treat Tennis and Golfer’s Elbow (and a host of other soft tissue conditions.)
The “Instrument Assisted” in IASTM refers to the idea that these instruments assist the practitioner in manipulating muscles and other tissues, rather than relying on pressure generated using only their hands, which is inherently tiring.
What’s The Goal Of These Therapy Techniques?
The objective is to break up areas of muscular, fascial or tendinous adhesion or scar tissue using these hand-held instruments, which can apply a uniform and often very firm, deep penetration in the tissue.
“IASTM is performed with ergonomically designed instruments that detect and treat fascial restrictions, encourage rapid localization and effectively treat areas exhibiting soft tissue fibrosis, chronic inflammation, or degeneration.”
“Instruments effectively break down fascial restrictions and scar tissue. The ergonomic design of these instruments provides the clinician with the ability to locate restrictions and allows the clinician to treat the affected area with the appropriate amount of pressure.”
“The technique itself is said to be a modern evolution from Traditional Chinese Medicine called Gua Sha…”
PHYSIO-PEDIA – Instrument Assisted Soft Tissue Mobilisation
https://www.physio-pedia.com/Instrument_Assisted_Soft_Tissue_Mobilization
In the image below, you can see an example of the technique being performed (in this case with Graston Tools) on a patient’s forearm to treat Tennis Elbow:
I absolutely agree that breaking up adhesions and scar tissue is fundamentally a KEY aspect in treating the underlying issue with Golfer’s and Tennis Elbow!
However, the big question, in my mind, is:
“Are these techniques are the best way to achieve this essential goal?”
My short and biased answer leans toward “I don’t think so” but more on that later. First let’s talk about the difference between the ancient and the modern.
What’s The Difference Between Gua Sha And IASTM?
As I quoted Physio-Pedia, above, modern IASTM techniques, like Graston are said to have evolved from the ancient Chinese Medicine technique, known as ‘Gua Sha.’ However…
“Gua Sha was not used to treat Musculoskeletal conditions but was traditionally applied along meridians to move the bad chi out through the skin.” – PHYSIO-PEDIA
So, we need to keep in mind that although Traditional Chinese Medicine (TCM) practitioners have certain tools and can apply them in a similar way to modern IASTM techniques, TCM practitioners are coming from a different perspective, and may have different objectives (although some may overlap.)
And those basic Chinese tools (made from animal horns, Jade and bamboo) are unlikely to be as precise as modern IASTM tools.
Video: Graston Technique Demo On Tennis Elbow Sufferer
Here’s a video by a skilled, trained Chiropractor, demonstrating the technique on the forearm of a patient with Lateral Epicondylopathy:
As far as the differences between the Graston Technique and it’s tools and all its “rival” techniques and tools, I think that would require a level of detail I don’t think is worth delving into at least at this time.
I think it’s fair to put them all in the same IASTM category / box – Just the same, Graston seems to be the original; the 1st generation, so here’s a slideshow with a little more detail about it:
By Touch Or By Tool? Manual Therapy Vs. Instruments
Soft tissue mobilization to release or “break up” areas of restriction, due to adhesion or scar tissue has traditionally been performed “manually” / by hand, using fingers, thumbs and even elbows.
Massage Therapists, (like myself) as well as Physical Therapists, Chiropractors, Chinese Medicine practitioners and other therapists have various levels of training in manual therapies and can develop very fine palpation skills.
Perhaps, I must allow, even while using IASTM tools, to some extent (?)
However, although the proponents of IASTM claim that skilled, experienced practitioners are able to “palpate” issues in the tissues of their patients…
I’m doubtful that any practitioner of these techniques can “feel” through these tools in a way that’s comparable to full, hands-on contact.
I would argue there’s nothing like direct, tactile contact, through fingers and thumbs.
And, although, I am not categorically against the idea of Graston or other IASTM therapies…
There are two things I would caution against or even oppose:
- Receiving treatment from any professional who doesn’t have significant training and experience in IASTM – (Especially from one who has a reputation for causing significant bruising and/or pain in their patients.)
- OR attempting to use these kinds of tools to treat yourself – (unless you have training in these techniques, of course)…
What about pain and bruising from this treatment?
If the practitioner uses a light enough touch with the instruments, these techniques are not necessarily painful.
In reality, though, the ability of these tools, when applied with even moderate pressure – (Combined with the tendency of many therapists and Chiropractors to be somewhat overzealous in their quest to deliver fast results!)…
Can all too easily result in “over-treating” the area.
Which can not only be an uncomfortable, if not outright painful experience – It can result in some significant side effects…
Possible Side Effects / Reactions To Instrument Assisted Treatment:
- Light bruising seems to be fairly common (which can last a few days)
- Mild, short-term redness is almost a given (due to the inflammatory histamine response)
- Petechiae pronounced pa-tee-kee-ah, is also common, (which is a form of tiny blood vessel breakage similar to bruising)
- And Massive bruising is a distinct possibility, especially for those who bruise easily (which can last a week or longer)
IASTM practitioners seem to frequently refer to these milder effects in their articles and videos as typical or even “desirable.”
According to Physical Therapist and IASTM advocate, Mike Reinold, however, bruising is not an inherent (or desired) result of Graston / IASTM
“IASTM should not make everyone black and blue! … IASTM is not about being so aggressive that you leave large purple marks and essentially produce superficial capillary hemorrhage. Some redness and petechia is OK, but the over aggressive black and blue is not ideal.”
– Mike Reinold, Champion Physical Therapy and Performance – ‘4 Myths Of IASTM‘
Here’s an example of some extensive bruising (probably from a Gua Sha treatment, I’m guessing) – And it’s on someone’s back, not their elbow or forearm but it gives you the idea:
Nevertheless, the issue remains – fact or myth, deserved or undeserved – these techniques have a notorious reputation for being painful and causing extensive bruising, which can leave big “black and blue” marks in the treated area.
The problem is that even the mildest bruising is a sign of tissue damage. (Bruising involves the rupture of capillaries, the tiniest blood vessels.)
Certainly it will be argued by some that the bruising is “worth it” in the big picture if the treatment works and the patient recovers from their injury or painful condition, so let’s examine that question…
Is IASTM Effective? What’s The Evidence?
The following study from 2016 appraised 7 randomized, controlled trials, five of which measured an IASTM treatment against a control group.
The Efficacy Of [IASTM] : A Systematic Review
“The results of the studies were insignificant (p>.05) with both groups displaying equal outcomes.”
“The current evidence of RCTs does not support the efficacy of IASTM for treating certain musculoskeletal pathologies.”
“…IASTM is a popular form of myofascial therapy but its efficacy has not been fully determined due to the paucity and heterogeneity of evidence.”
“There is a gap between the current research and clinical practice. …Future studies are needed to assess the different IASTM tools and IASTM protocols such as Graston® using strict methodology and fully powered controlled trials.”
Scott W. Cheatham, PT, PhD, et al Journal of Canadian Chiropractic Assoc. 2016 Sep; 60(3): 200–211. PMCID: PMC5039777
This paper, also on PUBMED, is a thorough read if you can handle the high level of jargon and technicality.
It covers the mechanism and effect of IASTM in great detail, but concludes that solid, clinical study data is lacking:
Therapeutic Effectiveness Of Instrument-Assisted Soft Tissue Mobilization For Soft Tissue Injury: Mechanisms And Practical Application
CONCLUSIONS: “…According to previous studies, IASTM was found to improve soft tissue function and ROM in acute or chronic sports injuries to soft tissues, while also reducing pain.”
“…However, most of the studies… were animal studies, with very few human studies. Published articles consist mostly of case reports rather than experimental studies.”
“Some of the case reports even failed to present the details of IASTM protocol that was applied. Therefore, the scientific basis for the mechanisms and effects of IASTM must be broadened through experimental studies in humans and the reliability of application protocol must be improved as well.”
Jooyoung Kim, Dong Jun Sung, and Joohyung Lee
Journal of Exercise Rehab, 2017 Feb; 13(1): 12–22. – Doi: 10.12965/jer.1732824.412
Fortunately, when it comes to Lateral Elbow Tendinopathy (Tennis Elbow) specifically, the following study comparing Astym to Eccentric Exercise appears to show significant evidence of effectiveness.
Astym Treatment Vs. Eccentric Exercise For Lateral Elbow Tendinopathy: A Randomized Controlled Clinical Trial
CONCLUSION: “This study suggests Astym therapy is an effective treatment option for patients with LE tendinopathy, as an initial treatment, and after an eccentric exercise program has failed.”
Thomas L. Sevier, Caroline W. Stegink-Jansen PeerJ. 2015; PMCID: PMC4451036
All of which leads to the what I believe may be the key question…
Because whether we’re talking about Astym, Graston or Gua Sha being used to treat tendon injuries, there is an element of force, and of what’s often referred to in the IASTM literature as “microtrauma.”
The question is: Is this scraping pressure and its likely trauma helpful and necessary?
(Trauma, at the very least, in the form of “minor” broken capillaries or Petechiae.)
In other words…
Is it necessary or even wise to create more trauma in the attempt to heal an injury?
YES and NO!
Two different perspectives and answers are necessary – depending on whether we’re talking about the muscles or tendons.
Tendons often need some kind of more direct, forceful intervention to break the vicious cycle of stagnation that is at the root of these kinds of painful tendon conditions.
(With muscles, however, this is not the case. They often have a lot of adhesions / scar tissue but MORE trauma is not required to release that scar tissue and free up the muscles. This can be accomplished more with finesse than force.)
And there may even be a point at which, having failed to heal a chronically painful, degenerated or torn tendon, it’s time to consider more invasive measures.
- Dry Needling is one possibility,
- Platelet-Rich Plasma injections being another,
- Surgery may even be called for in a minority of cases
And IASTM Therapy may fit the bill on the milder, less-invasive side (although still more aggressive than most purely hands-on techniques.)
The essence of these painful, chronic tendon conditions, like Tennis and Golfer’s Elbow, is stagnation and degeneration. – (Technically, Tendinosis)
Meaning, NOT ONLY a failure of the body’s healing capacity…
But a backwards slide away from repair / regeneration and into breakdown and degeneration.
Sometimes what’s needed is an outside force to “stimulate” a new healing response.
That’s the idea with Dry Needling, Platelet Rich Plasma Injection and Stem Cell Therapies.
By introducing new trauma – Anything from friction by hand, like the Cross Fiber Massage Techniques I teach and advocate (On the milder side)…
To potentially more forceful IASTM Techniques…
To actually piercing the skin to inject something (and literally punching holes in the tendon with Dry Needling and PRP Therapies.)
(Or even cutting the skin to surgically remove diseased or torn tendon tissue.)
ALL of which results in an inflammatory response – Which is necessary and good!!!
Because it’s the first stage of healing…
And, hopefully, it’s followed by repair / regeneration and remodeling (the 2nd and 3rd stages.)
From my perspective and in my experience, though, I just don’t believe it’s necessary to go to those extremes in the vast majority of cases.
I’ve been working on people by hand (without tools – IASTM Tools or others) and helping Golfer’s and Tennis Elbow sufferers recover at a high rate of success…
And specializing in these painful, difficult and extremely frustrating injuries for the past 15 years or so.
As well as teaching my student / members here in the Tennis Elbow Classroom self help programs how to use these advanced self-massage techniques on themselves to recover at home.
I’m convinced it’s enough to manipulate by hand – and to “strategically irritate” with Cross-Fiber Friction Massage – the tendons involved…
To stimulate enough of a healing response in your tendons… To jump start RE-generation and break the cycle of DE-generation.
And as part of a complete program to also release all the Scar Tissue / adhesions in your related MUSCLES!
And stretch and strengthen those muscles with the appropriate stretches and rehab exercises.
(As I said earlier, the muscles involved in these tendon conditions often have a lot of adhesions / scar tissue, which needs to be freed up to take the load off the tendons, but MORE trauma is not required to release it! Finesse – Not force.)
It’s also critical that you’re prepared to abandon (or drastically reduce) your reliance on the “common wisdom” Tennis Elbow treatments.
These “treatments” do not assist and support your healing process.
One or two may be neutral – but most inhibit your healing process, slowing it down – Or they outright suppress it:
- Icing / Cryotherapy inhibits circulation and healing,
- Anti-inflammatories suppress the natural inflammation response
- Braces and splints constrict and immobilize – Not helpful
- And Cortisone Shots actively suppressing healing – and CAUSE degeneration
You can learn more about my perspective and strategy for treating Tennis Elbow here – And learn more about my self-help programs for student/members, below:
Learn To Treat And Heal Your Own Tennis Elbow Or Golfer’s Elbow At Home With This Video Program
You’ll get instant access to a complete VIDEO program designed by a professional therapist to help you take charge and break your vicious cycle of pain and frustration!…I’ll be your personal tutor guiding you through step-by-step video lessons, where you’ll get the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (Without any special equipment.)
Just watch the videos, follow along and start putting an end to your elbow pain today!
Tennis Elbow sufferers: learn more and get started here
Golfer’s Elbow sufferers: learn more and get started here
While this is a fairly comprehensive overview of IASTM, I’d like to point out some important points specifically in reference to Graston Technique®. You describe IASTM as an application of “scraping” pressure. As an experienced manual therapist, the term “scraping” makes me cringe. When I manipulate connective tissue, whether it be with my hands or an instrument, I apply pressure to either compress, stretch, or shear tissue. While an untrained individual may not appreciate the difference, Graston Technique® does not involve “scraping.”
You explain the goal is to “break up” scar tissue. I will argue we are not “breaking up” anything. We are applying specific forces into the tissue to stimulate specific physiologic processes. Graston Technique is a form of mechanotherapy. When cells sense a mechanical load, a biochemical reaction occurs within the cell itself, directing cellular activity influencing growth, remodeling, and repair, with the ultimate outcomes being altered tissue mass, structure, and quality. (Thompson WR, Scott A, Loghmani MT, Ward SR, Warden SJ (2016). Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical therapy, 96(4), 560-569). Studies have documented an increase in fibroblastic activity, improved collagen production and alignment, angiogenesis, mobilization of mesenchymal stem cells into circulation, as well as changes in neurophysiology. Perhaps “remodeling” scar tissue would be a more accurate description.
You describe the technique to be an evolution of gua sha. Gua sha and modern-day IASTM are very different. Gua Sha targets the skin and the capillaries with the intention of affecting blood stasis, while the Graston Technique® targets underlying muscles, tendons, ligaments, and fascia. Creating petechiae and subsequent bruising is the intent with Gua Sha, this is never intended with GT.
You describe Graston Technique® as being the same as all IASTM. You missed an important distinction. Graston Technique® is a sequential protocol. IASTM is just 1 component of this sequential protocol. The literature recognizes this important distinction. In the Cheatham article you quote, the author notes ” the best available evidence for the Graston® technique is the RCT by Burke et al. which followed the complete protocol.” In a more recent systematic review, the authors find “insufficient evidence supporting the use of IASTM as a stand alone treatment.” However, the authors point out “moderate evidence supports the use of IASTM combined with stretching and strengthening protocols when treating tendinopathies such as lateral epicondylitis.” (Lambert M, Hitchcock R, Lavallee K, Hayford E, Morazzini R, Wallace A, Conroy D, Cleland J. (2017) The effects of instrument-assisted soft tissue mobilization compared to other interventions on pain and function: a systematic review. Physical therapy reviews, 1-10.) The protocol the authors describe is the Graston Technique®.
You claim to be doubtful that “any practitioner of these techniques can “feel” through these tools in a way that’s comparable to full, hands-on contact.” If you were to listen to a patient’s heart beat, would you be best to use your ears alone, or a stethescope? Graston Technique® instruments are designed to amplify tissue texture, allowing the clinician to better identify abnormalities in the tissue. GT instruments do not replace a clinician’s hands. They are used to amplify what the clinician can feel in their hands.
Last, you claim “these techniques have a notorious reputation for being painful and causing extensive bruising.” GT-trained clinicians are trained to use appropriate pressure as to NOT cause pain or bruising. Graston Technique, LLC will only sell their instruments to clinicians who are properly trained. Graston Technique® facilitates endogenous regenerative and reparative pathways. It is a prescription for treatment and needs to be performed by a skilled clinician who is able to determine the appropriate dosage in order to achieve the optimal therapeutic load.
Thank you for taking the time to write such a well-thought out comment (although I think it may qualify as a “mini post” in itself – probably the longest comment I’ve ever had on a post! which is fine.)
For now, I just wanted to approve it and let you know that I plan on reflecting on all your points and will consider making some corrections or at least an addendum or two.
Thank you, Mike for your unending presence to help educate others on Graston Technique.